The Boys-Will-Be-Boys Defense

A recent front page New York Times article about the lack of psychiatric care for adolescent boys at an upstate New York juvenile detention center shouldn't surprise us. The juvenile justice system, in a sense, has become the largest child mental health system, and the child and adolescent psychiatrists there are in short supply. The question we should be asking ourselves is, why are so many teens with psychiatric disorders in jail?

In fact, 80 percent of incarcerated young people have a psychiatric disorder, and most of them, boys, have Attention-Deficit Hyperactivity Disorder (ADHD) as well as a conduct disorder. Girls tend to have ADD, not ADHD, and without the hyperactivity component, they are far less likely to develop the conduct disorders that lead to illegal behavior. We know this much, and yet we struggle to identify the children with ADHD and comorbid conduct disorders because of the myths and stigma surrounding psychiatric diagnoses and treatments.

Twenty-four years ago I was the director of a division of child and adolescent psychiatry at a medical center in an affluent New York City suburb. I evaluated a 10-year-old boy named Bradley, who looked like Dennis the Menace with a charming smile, freckles, and beautiful red hair. His parents reported that he was expelled from school for using racial slurs toward another student and for a long history of inattentiveness, impulsivity, and hyperactivity. His parents also told me they were concerned that their son pathologically lied - they'd caught him stealing money on at least three occasions. Unfortunately, though, Bradley's parents refused all treatment recommendations including medication, parent training, and behavior therapy. Bradley changed schools and over the years I heard from his family that he'd failed at several other schools, required residential treatment, and attended substance abuse programs until his run-ins with the law culminated with jail time for assault. Bradley never received the treatment he needed to manage his ADHD symptoms and his life took a tragic course. It's heartbreaking because he had extraordinary potential and an early intervention could have allowed him to succeed at school, work, and in his social relationships.

Longitudinal studies conducted over the past thirty-five years have compared hyperactive children ages 6-12 with normal children. The results have indicated that the greatest risk factor for developing antisocial behavior and drug abuse is chronic ADHD symptoms, along with at least one symptom of conduct disorder, such as stealing, bullying, or destroying property. At age 25, ADHD subjects in these studies had been arrested (47% vs. 24%), convicted of a crime (42% vs. 14%), and incarcerated (15% vs. 1%) significantly more than normal subjects.

But there has been some hopeful news: boys in these studies treated with methylphenidate (Ritalin) at ages 6 to 7 were six times less likely than boys treated at age 12 to become substance abusers in late adolescence. Identifying and treating ADHD and conduct disorders early can greatly decrease the risk of many young boys landing in jail later in life. The cost of evaluating and treating a child with ADHD, using a combined approach of psychotherapy and medication, is just a fraction of the $80,000 a year needed to house a child in the juvenile justice system.

We need more child and adolescent psychiatrists and psychologists to serve the teenagers in the juvenile justice system. But our first step should be to educate pediatricians, parents, teachers, and the public about ADHD and conduct disorders - real diseases whose sufferers bear little resemblance to cute comic strip characters like Dennis the Menace. A child with these diseases isn't a boy "just being a boy." ADHD and conduct disorders are diseases with very serious and expensive costs to affected children, their families, communities, and society at large.